Relation of Electrocardiographic Criteria for Left Atrial

Enlargement to Two-Dimensional Echocardiographic Left Atrial

Volume Measurements
Kwan S. Lee, MBBCha, Christopher P. Appleton, MDa,*, Steven J. Lester, MDa,
Terrence J. Adam, MD, PhDb, R. Todd Hurst, MDa, Carlos A. Moreno, BSa,
and Gregory T. Altemose, MDa
Left atrial (LA) enlargement by 2-dimensional (2-D) echocardiography predicts adverse
cardiovascular outcomes. Electrocardiographic (ECG) criteria for LA enlargement are
based on M-mode echocardiographic LA diameter, which is inferior to 2-D– derived LA
volumes. This study compared established ECG criteria for LA enlargement with atrial
volume obtained by 2-D echocardiography to determine if traditional ECG criteria accu-
rately represent LA chamber enlargement, therefore offering a low-cost screening tool. A
total of 261 randomly selected patients who underwent electrocardiography and 2-D
echocardiography were enrolled. ECG parameters and electronically derived P-wave me-
dians were analyzed with electronic calipers for maximal accuracy. LA volumes by 2-D
echocardiography were measured with Simpson’s method of discs, with enlargement
defined as 32 ml/m2. Sensitivity and specificity tables and receiver-operating characteristic
curves were constructed for each criterion. Univariate and multivariate analyses were
performed for predictors of 2-D echocardiographic LA enlargement. LA enlargement was
present in 43% of patients. ECG P-wave duration was the most sensitive for the detection
of LA enlargement (69%) but had low specificity (49%). Conversely, a biphasic P wave was
the most specific (92%) but had low sensitivity (12%). The maximum area under the
receiver-operating characteristic curve for any criterion was 0.64, too low to be of clinical
utility. In conclusion, established ECG criteria for LA enlargement do not reliably reflect
LA enlargement and lack sufficient predictive value to be useful clinically. These results
suggest that P-wave abnormalities should be noted as nonspecific LA abnormalities, with
the term “LA enlargement” no longer used. © 2007 Elsevier Inc. All rights reserved. (Am
J Cardiol 2007;99:113–118)

Left atrial (LA) enlargement measured using cardiac ultra- Methods

sound is associated with an increased risk for cardiovascular
events.1 Although cardiac ultrasound is noninvasive and
harmless, a less costly technique such as electrocardiogra-
phy for identifying LA enlargement would be desirable. To
our knowledge, all previous studies correlating electrocar-
diographic (ECG) criteria for LA enlargement with echo-
cardiographically defined LA enlargement have used M-
mode echocardiographically derived LA diameters.2–14 LA
enlargement as defined by echocardiographic volume mea-
surement is more accurate15 and a better predictor of car-
diovascular outcomes.16 This study was designed to deter-
mine the predictive value of established ECG criteria used
to define LA enlargement as assessed by echocardiographi-
cally derived LA volumes.
Divisions of aCardiovascular Diseases and bInternal Medicine, Mayo
Clinic Arizona, Scottsdale, Arizona. Manuscript received May 2, 2006;
revised manuscript received July 19, 2006 and accepted July 25, 2006.
*Corresponding author: Tel: 480-301-8000; fax: 480-301-8081.
E-mail address: cappleton@mayo.edu (C.P. Appleton).
This was a retrospective cross-sectional study, which ran-
domly selected adult patients who underwent transthoracic
echocardiography for any indication at our institution from
August 2001 to August 2003. The study was approved by
the Mayo Foundation Institutional Review Board.
We excluded patients who had not authorized the use of
their records, had no analyzable P waves on electrocardi-
ography, were not in sinus rhythm at the time of electro-
cardiography or echocardiography, and had pacemakers. All
patients underwent electrocardiography ⬍1 week after their
outpatient echocardiographic studies or ⬍1 day after their
echocardiographic studies if hospitalized. Age, gender, race,
height, weight, vital signs, body mass index, and body
surface area as well as history of hypertension, hyperlipide-
mia, diabetes, ischemic heart disease, stroke, or atrial fibril-
lation were recorded.
Measured variables were the presence, type, and degree
of native valvular heart disease, the left ventricular ejection
fraction, and LA volumes and ECG characteristics. Echo-
cardiographic data were derived from the measurements
obtained during patients’ clinical studies. Echocardio-
graphic studies were interpreted and vetted for quality and
accuracy by experienced staff echocardiographers. Two-

0002-9149/07/$ – see front matter © 2007 Elsevier Inc. All rights reserved. www.AJConline.org
doi:10.1016/j.amjcard.2006.07.073
114 The American Journal of Cardiology (www.AJConline.org)
Figure 1. Maximum and minimum LA volume measured by Simpson’s method of discs from the apical 4-chamber view at end-expiration apnea.
Figure 2. Electronic caliper measurement of negative terminal P-wave
duration of electronically derived V1 median, magnified (12⫻) using off-
line analysis software.
dimensional (2-D) LA volumes were assessed from the
apical 4-chamber view at end-expiration apnea using Simp-
son’s method of discs,17 as shown in Figure 1. LA maxi-
mum volume was obtained on the frame preceding mitral
valve opening at end-systole from the 4-chamber view.
Minimum volume was measured in a similar fashion at the
end of atrial contraction. Both were indexed to body surface
area. LA enlargement was defined as a maximal indexed
volume of 32 ml/m2, a value larger than defined as abnormal
by recent American Society of Echocardiography guide-
lines18 but well validated as predicting adverse clinical
outcomes.19 –22
Electrocardiograms were analyzed retrospectively for
previously validated P-wave parameters in relation to LA
size.2,3,5 Electrocardiograms were retrieved from a central
electronic database, and analysis of P-wave configuration
was performed by a single blinded interpreter using off-line
analysis software (Muse Information System version
005A.32, GE Marquette Medical Systems, Inc., Milwaukee,
Wisconsin). Lead waveforms were measured from electron-
ically derived medians of individual leads as described in
the manual Physician’s Guide to Marquette Electronics
Resting ECG Analysis. Electronic calipers with a resolution
to a millisecond were used during measurements from elec-
tronically magnified (12⫻) median waveforms, as shown in
Figure 2. Three measurements were performed for each
reading, and an average was obtained. P-wave criteria for
LA enlargement included P-wave duration in lead I, II, or
III ⬎110 ms2,5,7,8; P-wave notching in lead I, II, or III, with
interpeak distance ⬎40 ms (P mitrale)2,5,7; or area sub-
tended by the terminal negative component of a biphasic
P wave in precordial lead V1 ⬎40 ms · mm (Morris
index).2,3,5,7,9,11,23
Statistical analysis was performed with JMP version 5.12
(SAS Institute Inc., Cary, North Carolina). Descriptive sta-
tistics were obtained and are expressed as mean ⫾ SD
because most of the data approximated normal distributions.
Sensitivity and specificity tables with corresponding posi-
tive and negative predictive value tables were then created
to evaluate the performance of the ECG criteria in detecting
 Methods/ECG Criteria for LA Enlargement 115

Table 1 Table 2
Baseline characteristics of study population Sensitivity and specificity of individual electrocardiographic parameters
and combinations of parameters in predicting left atrial enlargement
Variable All Patients LA Size
defined by indexed volume ⱖ32 ml/m2
(n ⫽ 261)
ⱖ32 ml/m2 ⬍32 ml/m2 ECG Criterion Detection of LA Enlargement (ⱖ32 ml/m2)
(n ⫽ 113) (n ⫽ 148)
Sensitivity Specificity Positive Negative
Age (yrs) 67 ⫾ 15 71 ⫾ 11 64 ⫾ 16 Predictive Predictive
Women 53% 51% 55% Value Value
Caucasian 93% 98% 93%
Body surface area (m2) 1.9 ⫾ 0.3 1.9 ⫾ 0.3 1.9 ⫾ 0.3 P duration ⱖ110 ms in 69% 49% 51% 68%
Body mass index (kg/m2) 28 ⫾ 6 28 ⫾ 6 28 ⫾ 7 lead I, II, or III
Height (cm) 169 ⫾ 10 169 ⫾ 11 169 ⫾ 10 (criterion 1)
Weight (kg) 80 ⫾ 21 80 ⫾ 20 81 ⫾ 22 Biphasic P wave ⱖ40 12% 92% 52% 58%
History of ms in lead I,
hypertension 55% 62% 49% II, or III (criterion 2)
hyperlipidemia 44% 48% 41% Negative terminal P 46% 64% 49% 61%
ischemic heart disease 34% 51% 20% force in lead V1
diabetes 19% 23% 16% ⱖ40 ms · mm
mitral valve disease 5% 11% 0% (criterion 3)
atrial fibrillation 13% 19% 8% Criteria 1 and 2 4% 96% 46% 57%
stroke 12% 13% 10% Criteria 2 and 3 1% 99% 50% 57%
obesity 23% 22% 24% Criteria 1 and 3 20% 91% 64% 60%
Systolic blood pressure 130 ⫾ 21 133 ⫾ 22 129 ⫾ 19 Criteria 1, 2, and 3 5% 98% 67% 58%
(mm Hg) Criteria 1 or 2 or 3 77% 33% 47% 65%
Diastolic blood pressure 71 ⫾ 13 69 ⫾ 14 72 ⫾ 12
(mm Hg)
Left ventricular ejection 60 ⫾ 13 55 ⫾ 16 63 ⫾ 11 Results
fraction (%)
LA maximum volume, 60 ⫾ 24 80 ⫾ 21 44 ⫾ 13 In total, 261 patients were enrolled into the study by random
nonindexed (ml) selection. The characteristics of the study group are listed in
LA maximum volume, 32 ⫾ 13 43 ⫾ 11 23 ⫾ 6 Table 1. Of our study population, 106 (41%) were inpa-
indexed (ml/m2) tients. LA enlargement by 2-D echocardiographic maximal
LA minimal volume, 32 ⫾ 19 47 ⫾ 19 22 ⫾ 10
indexed volume was present in 43%. Patients with LA
nonindexed (ml)
LA minimal volume, 17 ⫾ 10 25 ⫾ 11 11 ⫾ 5
enlargement had a uniformly higher incidence of cardiovas-
indexed (ml/m2) cular co-morbidities and risk factors.
The 3 ECG criteria used to detect LA volume enlarge-
Data are expressed as mean ⫾ SD or percentage. ment performed poorly. Sensitivities and specificities of the
ECG criteria alone or in combination are listed in Table 2.
When used as individual tests, the highest sensitivity for LA
LA enlargement. The performance of ECG criteria for LA volume enlargement was with a P-wave duration ⱖ110 ms
enlargement was tabulated individually and in combination. in limb lead I, II, or III, but this had low specificity. The
The traditional thresholds defining positive test results were highest specificity for LA enlargement was for a bifid P
then tested by receiver-operating characteristic curve con- wave separated by ⱖ40 ms (P mitrale) in lead I, II, or III,
but this had low sensitivity. When ⬎1 criterion was present,
struction to identify optimal thresholds. To determine if a
sensitivity decreased, whereas specificity increased, without
quantitative association existed between the degree of
a change in predictive value.
abnormality in the ECG criteria and the degree of 2-D
P-wave criteria were tested with the construction of re-
echocardiographic LA enlargement, Pearson’s correla- ceiver-operating characteristic curves, as shown in Figure 3.
tion coefficients were calculated. Univariate analysis was The maximum area under the curve was greatest for a bifid
performed comparing LA enlargement with clinical, de- P wave in lead I, II, or III of 40 ms (P mitrale), at 0.64 (SE
mographic, and ECG characteristics. Logistic regression 0.09, 95% confidence interval 0.47 to 0.79). All 3 thresholds
was used as the nonparametric univariate statistical test. for ECG criteria closely approximated the accuracy points
The univariate statistical analysis used logistic regression detected by the receiver-operating characteristic curves,
to fit the dependent LA enlargement variable against the confirming that these were appropriate for maximal predic-
demographic, clinical, and ECG variables. Multivariate tive power.
analysis was then performed to determine if addition of Scatterplots of ECG criteria were constructed against LA
the ECG criteria improved the predictive ability of de- maximal indexed volume, as shown in Figure 4. The degree
termining LA enlargement above knowledge of basic of abnormality in all ECG criteria was associated with LA
clinical parameters. Results are expressed as odds ratios maximal indexed volume (p ⬍0.0001) but with low Pear-
with 95% confidence intervals. Backward stepwise elim- son’s correlation coefficients. Significant univariate clinical
ination was used for multivariate analysis, followed by predictors for LA enlargement were age, the left ventricular
selective forward regression to identify significant vari- ejection fraction, ischemic heart disease, left-sided valvular
ables. heart disease, history of atrial fibrillation, or history of
116 The American Journal of Cardiology (www.AJConline.org)

Figure 4. Scatterplots of ECG criteria versus LA maximal indexed volume

(in milliliters per square meter). CI ⫽ confidence interval.

hypertension. The only significant univariate traditional

Figure 3. Receiver-operating characteristic curves for traditional ECG ECG criteria of the 3 was a P-wave duration in lead I, II, or
criteria in detecting LA enlargement (32 ml/m2) identifying thresholds of III ⱖ110 ms (p ⫽ 0.003). Multivariate stepwise backward
greatest accuracy. AUC ⫽ area under the curve. CI ⫽ confidence interval; logistic regression analysis showed that the addition of all
sens ⫽ sensitivity; spec ⫽ specificity significant ECG parameters and criteria did not add incre-
 Methods/ECG Criteria for LA Enlargement
Table 3
Multivariate predictors of left atrial enlargement (ⱖ32 ml/m2) by
backward nominal regression*
Characteristic Odds 95% Confidence Wald p Value
Ratio Interval Chi-Square
Age (per 10 yrs) 1.3 1.1–1.7 7.2
Coronary artery 2.9 1.5–5.6 10.8
disease
Left ventricular 0.8 0.7–1.0 4.0
ejection fraction
(per 10%)
History of atrial 2.6 1.2–6.0 5.3
fibrillation
Left-sided valvular 3.8 1.2–12.5 4.8
disease
* Regression with these variables produced an r 2 value of 0.16.
mental value beyond that provided by patient demograph-
ics, as listed in Table 3.
Discussion
Whether electrocardiograms are interpreted by cardiologists
or automated proprietary algorithms, the term “LA enlarge-
ment” continues to be used in their clinical interpretation.
All previous studies supporting this ECG diagnosis on the
basis of echocardiographically defined LA enlargement
used a single length measurement of the left atrium by
M-mode echocardiography. Two-dimensional echocardiog-
raphy has been shown to be much more accurate in diag-
nosing LA enlargement15 and a more robust marker of
cardiovascular events than M-mode diameter,16 yet the re-
lation of P-wave abnormalities to 2-D LA volume has not
been studied. The purpose of this study was to readdress the
issue of diagnosing LA enlargement by ECG criteria using
new technology (electronically derived median ECG com-
plexes and using electronic ECG calipers) and a more ac-
curate standard for LA enlargement (2-D echocardiographic
volumes). Our study shows that current ECG criteria for LA
enlargement correlate poorly with 2-D echocardiographic
volume, with a predictive value that is too low to be clini-
cally useful in individual cases. In addition, when analyzed
by multivariate analysis, the ECG criteria did not add pre-
dictive value for diagnosing LA enlargement above that
obtained by simple demographics, despite criteria thresh-
olds that are appropriate for maximal predictive capability.
As listed in Table 2, the specificity of individual or com-
bined P-wave variables for identifying LA enlargement was
very high. However, in each case, the sensitivity was so low
that the predictive values remained in a range that would not
be clinically useful in our real-world clinical population.
Compared with previous studies using M-mode measure-
ments for defining LA enlargement, our results indicate
significantly lower specificity for the Morris index and a
prolonged P-wave duration.2,5,7,9,11 Our findings regarding
notched P-wave criteria (P mitrale) and LA enlargement are
similar to previous results showing very low sensitivity with
high specificity.2,5 Other features shown to be associated
with “ECG LA enlargement” have been LA pressure over-
load,13,24 atrial hypertrophy,25 or a combination of these
factors.13
117
The poor performance of ECG criteria in detecting LA
enlargement has been previously suggested12 and is not
surprising in light of the increased knowledge from electro-
physiologic studies over the past 20 years. The hypothesis
that LA enlargement would lead to prolonged atrial conduc-
0.007 tion time did not take into account that prolongation of the
0.001 P wave can be a manifestation of intra-atrial block,10,26
which is common in the elderly and not necessarily associ-
0.05 ated with LA enlargement. In addition, after reaching the
compensatory limits of LA hypertrophy, the atrium may
enlarge and fail with a decrease in voltage.
0.02
Signal averaging with median complexes is an estab-
0.03
lished technique for artifact filtering in computer analy-
sis,27,28 which has the advantage of excellent signal noise
diminishment. Given the resolution of electronic calipers
and the 12-fold magnification in this study, our method
would be expected to be more accurate than using a mag-
nifying glass with 5⫻ magnification, as was customary in
the original studies.
A second difference from the original M-mode studies is
a definition of LA enlargement that is indexed for body
surface area. Correction for body surface area is a standard-
ized attempt to normalize previously identified differences
in LA size with respect to gender, height, and weight.25,29
Recent studies that correlated LA volume and adverse car-
diovascular events were all indexed to body surface area
and used either the same definition for LA enlargement (32
ml/m2) or the alternative (28 ml/m2).1 Although this study
presents data based on the first definition, when we com-
pared the sensitivities and specificities using the alternative
definition, there was minimal difference. We did not study
volumes derived by magnetic resonance imaging, the cur-
rent gold standard for LA volume assessment. LA 2-D
volumes are approximately 15% smaller, probably because
of the geometric simplification of the atrium.30 Because the
2 volumes have similar slopes except for the underestima-
tion by 2-D echocardiography, a repeat of the current study
using magnetic resonance imaging LA volume would likely
result in similar results.
In conclusion, established ECG criteria for LA enlarge-
ment do not reliably reflect LA enlargement and lack suf-
ficient predictive value to be useful clinically.
Acknowledgment: We thank Paul Elko from GE Health-
care for his assistance in providing research regarding the
electronic measurement of electrocardiograms and Eliane
Purchase from the Library Department, Mayo Clinic Ari-
zona, Scottsdale, Arizona.
1. Abhayaratna WP, Seward JB, Appleton CP, Douglas PS, Oh JK, Tajik
AJ, Tsang TS. Left atrial size: physiologic determinants and clinical
applications. J Am Coll Cardiol 2006;47:2357–2363.
2. Hazen MS, Marwick TH, Underwood DA. Diagnostic accuracy of the
resting electrocardiogram in detection and estimation of left atrial
enlargement: an echocardiographic correlation in 551 patients. Am
Heart J 1991;122:823– 828.
3. Aronow WS, Schwartz KS, Koenigsberg M. Prevalence of enlarged
left atrial dimension by echocardiography and its correlation with atrial
fibrillation and an abnormal P terminal force in lead V1 of the elec-
trocardiogram in 588 elderly persons. Am J Cardiol 1987;59:1003–
1004.
118 The American Journal of Cardiology (www.AJConline.org)
4. Jin L, Weisse AB, Hernandez F, Jordan T. Significance of electrocar-
diographic isolated abnormal terminal P-wave force (left atrial abnor-
mality). An echocardiographic and clinical correlation. Arch Intern
Med 1988;148:1545–1549.
5. Munuswamy K, Alpert MA, Martin RH, Whiting RB, Mechlin NJ.
Sensitivity and specificity of commonly used electrocardiographic
criteria for left atrial enlargement determined by M-mode echocardi-
ography. Am J Cardiol 1984;53:829 – 832.
6. Perosio AM, Suarez LD, Torino A, Llera JJ, Ballester A, Roisinblit
JM. Reassessment of electrovectorcardiographic signs of left atrial
enlargement. Clin Cardiol 1982;5:640 – 646.
7. Termini BA, Lee YC. Echocardiographic and electrocardiographic
criteria for diagnosing left atrial enlargement. South Med J 1975;68:
161–165.
8. Chirife R, Feitosa GS, Frankl WS. Electrocardiographic detection of
left atrial enlargement. Correlation of P wave with left atrial dimension
by echocardiography. Br Heart J 1975;37:1281–1285.
9. Ikram H, Drysdale P, Bones PJ, Chan W. The non-invasive recognition
of left atrial enlargement: comparison of electro- and echocardio-
graphic measurements. Postgrad Med J 1977;53:356 –359.
10. Josephson ME, Kastor JA, Morganroth J. Electrocardiographic left
atrial enlargement. Electrophysiologic, echocardiographic and hemo-
dynamic correlates. Am J Cardiol 1977;39:967–971.
11. Waggoner AD, Adyanthaya AV, Quinones MA, Alexander JK. Left
atrial enlargement. Echocardiographic assessment of electrocardio-
graphic criteria. Circulation 1976;54:553–557.
12. van Dam I, Roelandt J, Robles de Medina EO. Left atrial enlargement:
an electrocardiographic misnomer? An electrocardiographic-echocar-
diographic study. Eur Heart J 1986;7:115–117.
13. Di Bianco R, Gottdiener JS, Fletcher RD, Pipberger HV. Left atrial
overload: a hemodynamic, echocardiographic, electrocardiographic
and vectorcardiographic study. Am Heart J 1979;98:478 – 489.
14. Bartall H, Desser KB, Benchimol A, Massey BJ. Echocardiographic
left atrial enlargement. Comparison of vectorcardiogram and electro-
cardiogram for detection. J Electrocardiol 1978;11:355–359.
15. Lester SJ, Ryan EW, Schiller NB, Foster E. Best method in clinical
practice and in research studies to determine left atrial size. Am J
Cardiol 1999;84:829 – 832.
16. Tsang TS, Abhayaratna WP, Barnes ME, Miyasaka Y, Gersh BJ,
Bailey KR, Cha SS, Seward JB. Prediction of cardiovascular outcomes
with left atrial size: is volume superior to area or diameter? J Am Coll
Cardiol 2006;47:1018 –1023.
17. Wang Y, Gutman JM, Heilbron D, Wahr D, Schiller NB. Atrial
volume in a normal adult population by two-dimensional echocardi-
ography. Chest 1984;86:595– 601.
18. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pel-
likka PA, Picard MH, Roman MJ, Seward JB, Shanewise JS, et al.
Recommendations for chamber quantification: a report from the Amer-
ican Society of Echocardiography’s Guidelines and Standards
Committee and the Chamber Quantification Writing Group, developed
in conjunction with the European Association of Echocardiography, a
branch of the European Society of Echocardiography. J Am Soc
Echocardiogr 2005;18:1440 –1463.
19. Tsang TS, Barnes ME, Gersh BJ, Takemoto Y, Rosales AG, Bailey
KR, Seward JB. Prediction of risk for first age-related cardiovascular
events in an elderly population: the incremental value of echocardi-
ography. J Am Coll Cardiol 2003;42:1199 –1205.
20. Barnes ME, Miyasaka Y, Seward JB, Gersh BJ, Rosales AG, Bailey
KR, Petty GW, Wiebers DO, Tsang TS. Left atrial volume in the
prediction of first ischemic stroke in an elderly cohort without atrial
fibrillation. Mayo Clin Proc 2004;79:1008 –1014.
21. Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB. Left atrial
volume as a morphophysiologic expression of left ventricular diastolic
dysfunction and relation to cardiovascular risk burden. Am J Cardiol
2002;90:1284 –1289.
22. Moller JE, Hillis GS, Oh JK, Seward JB, Reeder GS, Wright RS, Park
SW, Bailey KR, Pellikka PA. Left atrial volume: a powerful predictor
of survival after acute myocardial infarction. Circulation 2003;107:
2207–2212.
23. Morris JJ Jr, Estes EH Jr, Whalen RE, Thompson HK Jr, McIntosh
HD. P-wave analysis in valvular heart disease. Circulation 1964;29:
242–252.
24. Heikkila J, Hugenholtz PG, Tabakin BS. Prediction of left heart filling
pressure and its sequential change in acute myocardial infarction from
the terminal force of the P wave. Br Heart J 1973;35:142–151.
25. Romhilt DW, Scott RC. Left atrial involvement in acute pulmonary
edema. Am Heart J 1972;83:328 –331.
26. Spodick DH. Unappreciated prevalence of interatrial block and asso-
ciated consequences: a poorly perceived pandemic. Mayo Clin Proc
2004;79:668 – 670.
27. Willems JL, Zywietz C, Arnaud P, van Bemmel JH, Degani R, Mac-
farlane PW. Influence of noise on wave boundary recognition by ECG
measurement programs. Recommendations for preprocessing. Comput
Biomed Res 1987;20:543–562.
28. Willems JL, Arnaud P, van Bemmel JH, Bourdillon PJ, Degani R,
Denis B, Graham I, Harms FM, Macfarlane PW, Mazzocca G, et al. A
reference data base for multilead electrocardiographic computer mea-
surement programs. J Am Coll Cardiol 1987;10:1313–1321.
29. Pritchett AM, Jacobsen SJ, Mahoney DW, Rodeheffer RJ, Bailey KR,
Redfield MM. Left atrial volume as an index of left atrial size: a
population-based study. J Am Coll Cardiol 2003;41:1036 –1043.
30. Rodevan O, Bjornerheim R, Ljosland M, Maehle J, Smith HJ, Ihlen H.
Left atrial volumes assessed by three- and two-dimensional echocar-
diography compared to MRI estimates. Intl J Card Imaging 1999;15:
397– 410.